Provider Demographics
NPI:1730284324
Name:KORN, BRADFORD HENRY (DDS)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:HENRY
Last Name:KORN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4656 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6857
Mailing Address - Country:US
Mailing Address - Phone:260-432-3588
Mailing Address - Fax:260-459-0729
Practice Address - Street 1:4656 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6857
Practice Address - Country:US
Practice Address - Phone:260-432-3588
Practice Address - Fax:260-459-0729
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120072561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice